- 期刊
提升病人安全事件通報作業系統完整正確性
Enhancing the Comprehensiveness and Accuracy of Patient Safety Reporting System
摘要
本專案以醫院為例探討如何提升院病人安全事件通報作業系統完整性與正確性，計畫執行期間為2016年7月4日至2016年8月26日，從探討通報作業系統低完整性與正確性開始，以調查填寫事件來源最多的部門及錯誤率最高的地方，經深入探討後發現其問題為主要原因為:(1)作業準則不清楚；(2)單位制度與通報準則矛盾；(3)通報重複之疑慮；(4)綜合式表格易混亂；(5)不清楚病安通報內容；(6)病安文化待提升。由專案小組成員利用決策矩陣圖，決定執行改善對策方案為:(1)修訂病人安全作業相關準則，強調準則適用範圍，警訊事件也需於「線上病人安全自主通報系統」反應；(2)表格格式修正:病人安全類別與其他類別可做特別標示，以粗黑體或放大字形另外註明各類別其內容；(3)每年定期舉辦有關病人安全的課程，病人安全通報系統使用介紹加強人員通報的認識；(4)製作標準病安通報流程，張貼於各單位；(5)利用院內電腦螢幕保護程式的畫面，加強宣導推廣病安文化。利用這些方案的改善使人員能以糾正對於病人安全作業的認知，並以正面的心態面對事件的發生及處理，共同維護並建立安全的醫療環境。
並列摘要
This project intended to enhance the comprehensiveness and accuracy of patient safety reporting system (PSRS) of the case hospital. We investigated the major source of reported events and units with low accuracy rate in July and August 2016. The major problems of unspecified reporting SOP, incongruity of reporting SOP and department code, doubled reporting, lack of standardized reporting format, employees did not familiar with the content of PSRS, and need for corporate culture of patient safety were identified. We utilized decision matrix analysis, and finalized the following strategies: 1) modify the SOP of PSRS, specify the conditions of reporting, and online reporting for sentinel events; 2) modify the reporting forms, categorize the patient safety events with visible marks of bold face and large font; 3) in order to familiar with the PSRS, all employees are mandatory for patient safety courses annually; 4) all units are required to post the SOP of PSRS at visible sites; and 5) design banners promoting the culture of patient safety on screen saver program for all PC monitors. In order to establish and maintain safe worksite, we expect these strategies will be able to enhance employees' concept of patient safety and offer positive attitude of handling patient safety events.